Intervention Summary

Promoting Alternative THinking Strategies (PATHS), PATHS Preschool

Promoting Alternative THinking Strategies (PATHS) and PATHS Preschool are school-based preventive interventions for children in elementary school or preschool. The interventions are designed to enhance areas of social-emotional development such as self-control, self-esteem, emotional awareness, social skills, friendships, and interpersonal problem-solving skills while reducing aggression and other behavior problems. Skill concepts are presented through direct instruction, discussion, modeling, storytelling, role-playing activities, and video presentations. The elementary school PATHS Curriculum is available in two units: the PATHS Turtle Unit for kindergarten and the PATHS Basic Kit for grades 1-6. The curriculum includes 131 20- to 30-minute lessons designed to be taught by regular classroom teachers approximately 3 times per week over the course of a school year. PATHS Preschool, an adaptation of PATHS for children 3 to 5 years old, is designed to be implemented over a 2-year period. Its lessons and activities highlight writing, reading, storytelling, singing, drawing, science, and math concepts and help students build the critical cognitive skills necessary for school readiness and academic success. The PATHS Preschool program can be integrated into existing learning environments and adapted to suit individual classroom needs.

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoWhiteRace/ethnicity unspecified

Settings

School

Geographic Locations

UrbanSuburbanRural and/or frontier

Implementation History

Since its development in the early 1980s, PATHS has been delivered to an estimated 865,600 students in all 50 States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and internationally in an estimated 10,500 classrooms. PATHS has been used in a variety of schools, including those for children with special needs (e.g., deafness, learning disabilities, autism spectrum disorders). Outside the United States, PATHS has been implemented in Australia, Belgium, Bermuda, Brazil, Canada, Croatia, Czech Republic, England, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Japan, Mexico, the Netherlands, New Zealand, Norway, Peru, the Philippines, Scotland, Singapore, South Africa, South Korea, Switzerland, Taiwan, and Wales.

Since its development in 2005, PATHS Preschool has been implemented in 45 States and the District of Columbia. Outside the United States, PATHS Preschool has been implemented in Argentina, Australia, Canada, Chile, England, France, Greece, Hong Kong, Ireland, Israel, Jamaica, the Netherlands, Poland, Scotland, Singapore, Taiwan, Turkey, and Wales. The intervention has reached an estimated 4,600 classrooms and at least 63,500 children.

NIH Funding/CER Studies

Partially/fully funded by National Institutes of Health: YesEvaluated in comparative effectiveness research studies: No

Adaptations

PATHS materials have been translated into Croatian, Dutch, French, German, Greek, Hebrew, Spanish, and Welsh. Parent materials are available in Spanish. PATHS has been adapted for use with after-school programs in Kansas, New York, Ohio, Pennsylvania, Washington, and West Virginia.

Preschool PATHS has been translated into Dutch, Korean, and Spanish and has been successfully adapted for use in Head Start programs in Pennsylvania, where it has been tested in a randomized trial at two sites.

Adverse Effects

No adverse effects, concerns, or unintended consequences were identified by the developer.

IOM Prevention Categories

Universal

Quality of Research

Review Date: May 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.

Study 2

Kam, C.-M., Greenberg, M. T., & Kusché, C. A. (2004). Sustained effects of the PATHS curriculum on the social and psychological adjustment of children in special education. Journal of Emotional and Behavioral Disorders, 12(2), 66-78.

Outcomes

Outcome 1: Emotional knowledge

Description of Measures

In one study, the Kusché Affective Interview--Revised (KAI-R) was used to assess understanding of emotions and ability to provide examples of personal experience with different emotions. Five domains of emotional understanding were assessed among 2nd- and 3rd-grade children in regular education and special education classrooms: (1) ability to discuss one's own emotional experiences, (2) cues used to recognize emotions, (3) issues regarding the simultaneity of emotions, (4) display rules for emotions, and (5) whether and how emotions can change.

In another study, the revised version of the 30-item Recognition of Emotion Concepts subtest from the Kusché Emotional Inventory was used to assess preschool children's receptive emotion vocabulary. For each item, children were presented with four cartoon drawings and asked to identify the picture that corresponded to the emotion named by the interviewer.

In the same study, the Assessment of Children's Emotions Scales (ACES) was used to assess preschool children's emotion expression knowledge and to determine whether they exhibited any anger bias. Children were presented with 12 photos of elementary school-aged children posing with various facial expressions and were asked how each child in the photos felt. The emotion accuracy score reflected how many items a child answered correctly. The anger bias score was the percentage of time children incorrectly identified the faces as displaying anger.

Key Findings

Children in special education and regular education classrooms who received PATHS showed improvements relative to children in comparison schools in several areas, including affective vocabulary range (p < .001); ability to provide appropriate personal examples of the experience of basic feelings (p < .001); beliefs that they can hide, manage, and change their feelings (p < .001); and understanding of cues for recognizing feelings in others (p < .01).

Among children in special education classrooms, those who received PATHS improved significantly relative to those in comparison schools in their understanding of how others manage and hide their feelings (p < .05) and how feelings can be changed (p < .01).

Among children in regular education classrooms, the children exposed to PATHS experienced improved comprehension of complex feelings (i.e., proud, guilty, jealous, nervous/anxious, lonely) compared with children in classrooms without the intervention (p < .01).

Preschool children who received the PATHS Preschool intervention demonstrated a larger receptive emotion vocabulary at posttest relative to children in comparison classrooms (p < .01). They also were more accurate in identifying feelings (p < .05). In addition, exposure to the intervention significantly reduced children's anger attribution bias (p < .01). Effect sizes for receptive emotion vocabulary, identification of feelings, and anger attribution bias were small (Cohen's d = 0.36, 0.37, and 0.40, respectively).

Teachers of children in 2nd- and 3rd-grade regular education classrooms and 1st- through 3rd-grade special education classrooms rated their students' internalizing behavior symptomatology using the Child Behavior Checklist--Teacher Report Form (CBCL-TRF), a 118-item checklist of behavioral and emotional problems commonly seen by teachers.

The internalizing behaviors of preschool children were rated by teachers using the Problem Behavior Scale of the Preschool and Kindergarten Behavior Scales (PKBS), which includes two internalizing behavior subscales: Social Withdrawal and Anxiety/Somatic Problems. Items were rated on a 4-point scale from 0 (never true) to 3 (often true).

Key Findings

Teacher ratings of internalizing behaviors in children in special education classrooms who received a modified version of the PATHS Curriculum increased at a rate of 0.38 points per year over 3 years. In contrast, ratings of comparison group children increased at a much higher rate of 1.83 points per year over the same period (p < .05). The effect size for this finding was small (Cohen's d = 0.22).

Children in regular education classrooms who participated in PATHS demonstrated fewer internalizing behaviors at 1-year follow-up than did comparison group children (p < .05).

In one study, preschool children who were exposed to PATHS Preschool were significantly less likely at the end of the school year to be described by their teachers as anxious (rural study site only, p < .01) or withdrawn or lacking friends (p < .05) relative to children in comparison classrooms. The effect size for social withdrawal was small (Cohen's d = 0.24).

Children's externalizing behavior symptomatology was rated using teacher and peer reports. In two separate studies, teachers of children in 2nd- and 3rd-grade regular education classrooms and 1st- through 3rd-grade special education classrooms rated their students' externalizing behavior symptomatology using the CBCL-TRF. In another study conducted in high-risk schools (defined by estimated rates of delinquency and juvenile arrest in the neighborhoods), aggressive and hyperactive-disruptive behavior of children in 1st-grade classrooms were rated by peers using individual sociometric interviews. The child raters were asked to name one or more students from their class who matched descriptions of children with aggressive and hyperactive-disruptive behavior. After the sociometric scores for each classroom were corrected for the number of raters, the classroom mean scores for all children were standardized across the entire sample within each of the three cohorts of 1st-graders who received the intervention.

Key Findings

Teacher ratings of externalizing behaviors in children in special education classrooms who received a modified version of the PATHS Curriculum decreased at a rate of 0.37 points per year over 3 years. In contrast, ratings of comparison children increased at a rate of 0.72 points per year over the same period (p < .05). The effect size for this finding was very small (Cohen's d = 0.18).

Children in regular education classrooms who participated in PATHS demonstrated fewer externalizing behaviors at 1-year follow-up than did children in the comparison group (p < .05).

Children in high-risk schools who received an adapted version of PATHS had lower average aggression and hyperactive-disruptive behavior scores than children in comparison classrooms (p = .03 and p = .02, respectively). Effect sizes for aggression and hyperactive-disruptive behavior were small (Cohen's d = 0.22 for both analyses).

Children in 1st- through 3rd-grade special education classrooms completed the Children's Depression Inventory (CDI), a 27-item self-report measure of depression. For each item, the child was asked to describe his or her feelings during the past 2 weeks, with three possible response options associated with scores of 0 (an absence of symptoms), 1 (mild symptoms), and 2 (definite symptoms). The total score could range from 0 to 54.

Key Findings

The depression scores reported by students who received a modified version of the PATHS Curriculum declined at a rate of 3.7 points per year over 2 years, whereas the scores for children in the comparison classrooms decreased at a rate of 0.85 points per year over the same period (p < .05). The effect size was small (Cohen's d = 0.49).

Inhibitory control and verbal fluency, neurocognitive abilities thought by developers to mediate social competence, were examined in children in 2nd- and 3rd-grade regular education classrooms. Inhibitory control was measured by the Stroop Test, in which the names of colors are presented in different colors of ink (e.g., the word "red" printed in blue ink). For each item, students were asked to ignore the word itself and identify the color of the ink in which the word was printed.

The Verbal Fluency Subtest of the McCarthy Scales of Children's Abilities was used to assess verbal concept formation, logical classification, verbal expression, and creativity. Children were given 20 seconds to name as many items as they could in each of four common categories (things to eat, animals, things to wear, and things to ride).

Key Findings

Children who participated in the PATHS intervention demonstrated greater inhibitory control and verbal fluency at 1-year follow-up than did children in comparison classrooms (p < .01 for both analyses).

For 30 minutes on 2 different days, trained, unbiased observers watched 1st-grade children previously identified as high risk (demonstrating the greatest degree of early conduct problems) in their classrooms. The classrooms were all in high-risk schools, defined by estimated rates of delinquency and juvenile arrest in the neighborhoods. To assess the quality of the classroom atmosphere, the observers rated 10 items derived from the Classroom Rating Form on a scale from 1 (low) to 5 (high): (1) level of disruption during academic time, (2) ability to handle classroom transitions, (3) ability to follow rules, (4) level of cooperation, (5) use of problem solving during conflict or need, (6) ability to express feelings appropriately, (7) level of interest and enthusiasm, (8) ability to stay focused and on task, (9) responsiveness to individual student's needs and feelings, and (10) level of criticism versus supportiveness. A mean score for each rating and a total classroom atmosphere score were computed for each classroom, with lower scores indicating a more positive atmosphere.

Key Findings

Classrooms exposed to an adapted version of the PATHS Curriculum were rated as having a more positive classroom atmosphere than comparison classrooms (p < .01). According to exploratory analyses, results on 4 of the 10 separate rating scales were statistically significant: ability to follow rules (p < .05), ability to express feelings appropriately (p < .05), level of interest and enthusiasm (p < .01), and ability to stay focused and on task (p < .005).

Social-emotional competence of preschool children was measured using both teacher and parent ratings. Teachers completed the Social Skills Scale of the PKBS. This 34-item scale describes adaptive or positive behaviors across three subscales: Social Cooperation, Social Interaction, and Social Independence. Parents completed the Head Start Competence Scale (HSCS), a 12-item measure of children's social and emotional skills that reflects interpersonal relationships and emotion regulation.

Key Findings

At posttest, teachers who taught the PATHS Preschool program described their students as significantly more cooperative (only for children with higher mean levels of verbal ability), emotionally aware, and interpersonally skilled than did teachers in the comparison classrooms (p < .0001 for the social skills composite score). The effect size for the composite social skills rating was small (Cohen's d = 0.48).

Parents of preschool children who received the PATHS Preschool program described their children as significantly more socially and emotionally competent than did parents of children in comparison classrooms (p < .01). The effect size was small (Cohen's d = 0.36).

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:

Reliability of measures

Validity of measures

Intervention fidelity

Missing data and attrition

Potential confounding variables

Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome

Reliability
of Measures

Validity
of Measures

Fidelity

Missing
Data/Attrition

Confounding
Variables

Data
Analysis

Overall
Rating

1: Emotional knowledge

3.0

2.3

2.5

2.0

2.8

2.8

2.5

2: Internalizing behaviors

3.0

3.0

3.0

2.9

2.8

3.0

2.9

3: Externalizing behaviors

2.8

3.0

3.0

3.0

2.8

3.0

2.9

4: Depression

3.5

3.8

2.5

3.5

2.8

3.0

3.2

5: Neurocognitive capacity

2.5

2.5

3.0

2.5

2.8

3.3

2.8

6: Learning environment

2.5

2.3

2.8

2.3

2.8

3.0

2.6

7: Social-emotional competence

3.3

2.8

3.0

2.0

3.0

3.0

2.8

Study Strengths

The studies used a randomized control group design and a multimethod assessment strategy that included interviews, observation, and teacher ratings. Most of the measures used are well known and have established psychometric properties. Teachers were provided training, and project staff observed and consulted with the teachers each week. Instruments were used to monitor and track intervention fidelity. Most teachers were rated as doing an "adequate or better" job in using the curriculum, and the mean number of lessons taught indicates that most teachers administered the whole curriculum. Attrition and missing data varied across the studies but were addressed with statistical methods. Cross-rater estimates used in several of the studies showed that the intervention affected the study's findings. Analytic methods appear to have been appropriate.

Study Weaknesses

The studies did not adequately address the validity of the sociometric interviews. Teachers made modifications to the intervention, but those modifications and their effects are not clear. Most of the children in special education classrooms completed only a small number of problem-solving lessons. There were some problems with attrition, largely due to children moving during the school year.

Readiness for Dissemination

Review Date: May 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.

Dissemination Strengths

The program materials include everything that an individual or school would need to implement the program, with detailed instructions for using each component as well as creative supplemental materials to engage children and families. On-site, individualized training is available for implementation sites to help them tailor the program to the local culture and identify and address local needs, strengths, and barriers to implementation. An evaluation kit is provided to support quality assurance.

Dissemination Weaknesses

Training is available for a fee but is not required. No initial or continuing education is available that brings together implementers from different sites for networking or peer-to-peer learning opportunities. No guidance is provided for interpreting and using the information derived from process evaluation measures to support quality assurance. Materials also do not include any tools for assessing the satisfaction or perceptions of parents.

Costs

The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.